Since Ivan Sutherland and Bob Sproull created the first virtual reality (VR) headset in 1968, VR technology has evolved significantly [1]. VR involves experiencing digital simulations, ranging from realistic to fantastical, in 3D spaces using computer technology [2]. Users can experience VR in immersive and nonimmersive forms. Today, VR technology is widely used in gaming, entertainment, education, and therapy.

In the medical field, VR has gained recognition as a nonpharmacological tool for psychosocial and physical therapy. Research has consistently shown VR’s capacity to enhance mental health and cognitive abilities while diminishing symptoms of depression [3-6]. VR can assist in physical recovery and facilitate postsurgical rehabilitation in various clinical settings [7-9]. With the aging population and the cost of chronic pain potentially reaching up to US $635 billion annually [10], VR has also been developed to relieve persistent pain. Studies have validated its efficacy in pain reduction using techniques such as distraction, relaxation, graded exposure therapy, and pain management education [11-14]. Various VR applications have been designed and built specifically for chronic pain therapy. These include, but are not limited to, applications for lower back pain [15], neck pain [16,17], migraine headaches [18], knee osteoarthritis [19], and regional pain [20-22]. These VR applications are often used under the guidance of health care professionals such as physiotherapists or occupational therapists [16-18,21,22].

On the other hand, as chronic pain can affect various body parts, different studies have indicated the potential benefits of commercial-off-the-shelf VR applications for individuals with persistent pain [23-26]. One study explored the efficacy of using 12 commercial VR applications to provide veterans with chronic pain therapy, ranging from low-intensity distraction to high-intensity movement-based exposure. Benefits included reducing kinesiophobia, improving patient-specific functioning, and delivering pain distraction [23]. Another study aimed to desensitize a patient to visually evoked pain by using the Vacation Simulator (Owlchemy Labs), a commercial VR application. The results showed that the intervention could nearly extinguish the visually evoked pain by the end of the program [25]. Commercial VR applications may benefit individuals with chronic or multiple pain conditions, particularly those needing regular physical exercise [26-28]. Immersive commercial VR games can motivate people to work out to improve their health.

Locally, since 2005, the Hong Kong Hospital Authority has implemented VR for functional rehabilitation in walking, upper and lower limb movement, fall prevention, cognitive ability, and driving reaction, in which therapists supervise nonimmersive VR training to ensure patient safety [7]. However, research on VR’s efficacy for chronic pain remains limited. Two systematic reviews found VR to be effective in reducing chronic pain levels [29,30], but one study highlighted that its impact might depend on the methodology and strategies used in the research [29]. Moreover, 5 clinical trials in Hong Kong explored VR’s use in pain alleviation, but most trials primarily focused on acute pain relief in clinical settings such as peripheral intravenous cannulation [31], venipuncture [32], palliative care [33], and elective surgery [34]. Only one recent clinical trial demonstrated chronic pain reduction through VRiKnee [35], a designated VR application for knee osteoarthritis.

The challenges outlined above highlight the need to explore the use of commercial VR applications for older adults in the community in a local setting, without relying on high-cost, high-turnaround-time, tailor-made VR applications. However, the number of localized and commercial VR applications is limited. While international studies have explored commercial VR applications to manage chronic pain or well-being, many required participants to understand English. This often excluded older adults with limited English proficiency, as these applications were primarily in English. In addition, concerns regarding cultural nuances and perceived limited technological literacy were factors for exclusion in many studies [36-38]. Researchers often either specifically designed VR applications or used native-language and commercial-off-the-shelf VR applications for older adults in the community. There has been little research exploring the feasibility and effectiveness of applying nonlocalized, commercial VR applications to manage chronic pain and well-being in the population.

The main objectives of this study were to (1) evaluate the feasibility of using commercial-off-the-shelf VR applications for managing chronic pain among older adults, (2) assess the efficacy of VR in alleviating chronic pain, and (3) examine its impact on the well-being of older adults in a community setting.

This study was a single-arm, mixed methods pilot study conducted between January and March 2024 at an elderly day care center in Hong Kong. The study was approved by the Ethical Committee of the Hong Kong Metropolitan University (reference no HE-RD/2023/1.15). Participants signed an informed consent form and completed a questionnaire that included demographic information, the Numeric Pain Rating Scale (NPRS), pain self-efficacy, medical history queries, and their VR experience for initial screening. The study comprised two major stages: preparation and implementation. This paper is reported under the CONSORT (Consolidated Standards of Reporting Trials) 2010 extension for pilot and feasibility studies (items 1a-12b, as applicable to a nonrandomized, single-arm design).

This exploratory feasibility pilot followed Julious’ [39] rule-of-thumb of 12 participants for pilot work. Accounting for possible attrition, we aimed for 14 enrollments and achieved 13 complete datasets. Using the large pre-post mood effect observed here (Cohen d=1.82), a conventional two-arm superiority trial would need roughly 34 participants in total (17 per arm) to provide 80 % power at α=.05, calculated with G*Power 3.1 (Heinrich Heine University Düsseldorf).

This stage consisted of four key steps before the formal study: theory setting, game selection, recruitment, and a pre-pilot study.

We gathered two categories of data: demographic and outcome data. Demographic data were collected at baseline when the potential participants had signed the consent form expressing their interest in joining the VR intervention.

The outcome data consisted of several measures: the World Health Organization–Five Well-Being Index (WHO-5), the NPRS, and assessments of pain self-efficacy, the Mood, and the feasibility of the VR intervention. In addition, we collected qualitative feedback from the participants after the last VR session.

To have a general picture of the effectiveness of VR in managing chronic pain and the well-being of the participants, the three outcome variables—NPRS, Pain Self-Efficacy, and WHO-5—were assessed before the first VR session (BT1) and after the end of the last VR session (AT3). To differentiate any potential change in mood before and after each VR intervention, the outcome variable “mood” was collected every time before (BT1, BT2, and BT3) and after each VR session (AT1, AT2, and AT3). In addition, the participants were checked to see if they had any discomfort immediately after every VR session. If the participants reported discomfort, they were assessed for VR sickness to understand the specific areas of discomfort.

Data analysis was performed using IBM SPSS Statistics (version 29.0). Descriptive statistics, including counts, SDs, means, and proportions, were calculated for demographic data and feasibility factors.

The Shapiro-Wilk test was used to assess data normality for outcome variables, including NPRS, Pain Self-Efficacy, WHO-5, and Mood. In addition, Les Mills BODYCOMBAT performance scores, postintervention WHO-5 scores, and average mood scores after VR sessions were evaluated separately for group analysis.

Mann-Whitney U tests and independent sample t tests were used to compare group differences based on data normality. Cohen d was calculated to assess the magnitude of VR’s impact on parametric variables. Statistical significance was set at a 2-tailed P<.05. Responses to the final open-ended questions were transcribed and analyzed using a combination of traditional and inductive content analysis methods, as recommended by Vaismoradi et al [60].

All hypothesis tests were exploratory; no formal adjustment for multiplicity was applied, so results should be interpreted with caution regarding potential type I error inflation.

Because multiple outcomes were analyzed without formal adjustment, P values near the threshold (eg, pain self-efficacy, P=.03) should be viewed as exploratory due to potential type I error inflation.

The study was conducted following the Declaration of Helsinki and approved by the Research Ethics Committee of Hong Kong Metropolitan University (HE-RD/2023/1.15). All participants provided written informed consent permitting both primary data collection and secondary analysis of deidentified data. Datasets were pseudoanonymized with numeric identifiers, and the data analyst did not have access to the reidentification key. This key was securely stored on an encrypted, password-protected device accessible only to senior members of the research team not involved in data analysis. Participants received HK$150 (ie, US $19.11) supermarket coupons as compensation for their participation. Illustrative photographs do not allow identification because VR headsets and surgical masks obscure the face; a visible coauthor granted written permission for publication.

As shown in Figure 5, a total of 18 participants were recruited from the day care center. Of these, 5 were excluded based on eligibility criteria, resulting in a recruitment rate of 72.2%. During the 3 VR intervention sessions, 2 participants withdrew: 1 reported fatigue, and the other preferred not to participate further as it interfered with his usual mahjong activities. In total, 11 participants completed the intervention and were included in the final analysis.

Table 1 summarizes the baseline characteristics of the 13 participants. The participants had a mean age of 79.23 (SD 9.221). Eight participants reported having chronic pain for over 3 years, while the remaining 5 were nonpainful older adults. Most of the participants had attended primary school or below, lived with others, had no VR experience, and had no glaucoma or cataract. Among the participants, 9 (69.2%) of the participants used smart devices in daily life.

In addition to the sentiment analysis, we further coded the participants’ responses into three themes. Participant feedback is detailed in Multimedia Appendix 3.

This pilot study is one of the first to explore the feasibility and preliminary signals of nonlocalized, commercial-off-the-shelf VR applications for managing chronic pain and the well-being of community-dwelling older adults. The current study aimed to address three primary research questions: (1) evaluate the feasibility of using commercial-off-the-shelf VR applications for managing chronic pain among older adults, (2) assess the efficacy of VR in alleviating chronic pain, and (3) examine its impact on the well-being of older adults in a community setting. We found that nonlocalized commercial VR applications demonstrate good feasibility and acceptability in managing chronic pain among older adults in the community. However, their direct effects on pain intensity and overall well-being still need further exploration. These results will be discussed in detail in the following paragraphs.

First, regarding the feasibility of using commercial-off-the-shelf VR applications, VR applications have been developed specifically for chronic pain therapy or rehabilitation in clinical settings [15-22,32]. However, the high completion rates, low adverse outcomes, and positive qualitative feedback demonstrated good feasibility and acceptance of market-ready VR applications among older adults in the community. Unlike previous studies that highlighted limited English proficiency, digital literacy, and cultural relevance as challenges to VR use among older adults [36-38], our study found that a structured approach to explain key aspects to older adults and warm-up sessions before the VR intervention could effectively alleviate potential anxiety.

In addition, the practical implementation of commercial VR applications in real-world settings demonstrates considerable potential for scalability. For instance, the Meta Quest 3 is priced at approximately US $500, making it a relatively accessible technology. In contrast to other studies where VR interventions are typically administered by a qualified physiotherapist [26], a trained facilitator can also effectively oversee groups of 5-6 seated older adults after a single one-to-one orientation session. This ensures the safe and efficient use of VR applications. In addition, the option to conduct sessions at home eliminates transportation challenges, with informal caregivers able to lend support. This finding is consistent with previous studies demonstrating home-based VR therapy as a viable option for patients with chronic pain [61]. These practical factors collectively highlight the affordability, accessibility, and sustained engagement potential of commercial VR for older adults living in community settings.

Next, about the efficacy of VR for managing chronic pain and well-being, the pilot study yielded mixed results. The VR intervention showed a significant impact on emotional (immediate mood) and psychological aspects of pain management. Our qualitative findings also aligned with theoretical models [40-45], demonstrating that VR technology and exercise can provide psychological benefits. This result is consistent with the opinions of other researchers [62-64]. For instance, research showed that after receiving virtual reality hypnosis treatment, patients spent less time thinking about pain, and the reported intensity of the worst pain, anxiety, and pain discomfort were significantly reduced [63]. Distracting the participants’ attention during VR intervention may be an important psychological mechanism for pain relief [62-64]. However, no statistically significant change was detected in pain intensity or overall well-being (NPRS and WHO-5), possibly because self-efficacy might be cognitively mediated and may improve before nociceptive intensity responds [65]. This pattern aligns with contemporary pain models that emphasize affective–cognitive appraisal [66]. In small pilots, these outcomes, therefore, might not move in tandem. Larger, controlled trials with longer follow-ups are required to determine whether the psychological gains translate into clinically meaningful pain relief.

In addition, we detected no statistically significant differences in postsession mood, WHO-5 scores, or boxing-game performance between pain and nonpain participants. Although the small sample size limits broad conclusions, our results tentatively indicate that both subgroups could effectively use and enjoy the VR protocol. A larger, controlled trial is needed to confirm these findings.

This pilot study had several limitations that should be considered when interpreting the results. First, the study included a small number of participants in one center. The limited number of participants reduces statistical power, increasing the risk of not detecting true effects. Hence, a larger sample size from multiple centers would have provided higher statistical power for the analysis and broader applicability of the findings (refer to Multimedia Appendix 4 for the use of ChatGPT to improve the readability). For instance, based on the large mood improvement observed in this study (Cohen d=1.8), a two-arm trial would require approximately 34 participants per group to achieve 80% power at a 0.05 significance level.

Second, this single-arm design made it difficult to draw causal inferences about the VR intervention’s effectiveness. Because this was an uncontrolled, one-arm pilot, any pre-post change could equally be attributable to placebo effects, Hawthorne reactivity, or simple regression to the mean rather than to the VR content itself. To address these threats, we are currently planning a randomized controlled trial that will compare the same VR protocol with an attention-matched control condition.

Third, the short duration of each VR session might not have been sufficient to observe significant changes in chronic pain and well-being. Previous studies with longer and more intensive VR interventions have shown better outcomes [29]. This pilot study only collected immediate postsession outcomes; our forthcoming randomized trial will obtain 1- and 3-month follow-up data to establish the durability of effects. Future research should extend the duration and intensity of the intervention and align with physical exercise guidelines to enhance its impact. These trials should test longer interventions with a 1‐ to 3-month follow-up period to help determine if short-term psychological benefits lead to lasting reductions in pain and improvements in overall well-being.

As commercial-off-the-shelf VR applications may not fully support the local language, the research team tried to translate 360-degree videos and provided real-time interpretation for participants. However, this may still have limited participant engagement and enjoyment, as the experience was not fully immersive in their native language. While this served as a temporary solution, it highlights the need for developing native-language VR content. Future studies should prioritize VR applications in participants’ native languages whenever available (refer to Multimedia Appendix 4 for the use of ChatGPT to improve the readability). Furthermore, trials comparing language-localized and nonlocalized VR applications could show whether native-language content boosts engagement and adherence in older adults.

In addition, the reliance on self-reported measures introduced potential biases such as social desirability and recall errors. Future studies should incorporate objective measures such as the Medical Research Council (MRC) Scale for muscle strength or activities of daily living assessments to provide a more comprehensive evaluation. Performance scores from VR exercises, such as scores in Les Mills BODYCOMBAT, could also be used to objectively track progress and motivate participants, in line with self-determination theory. Future research should include objective measures of physical function, such as timed-up-and-go tests, Medical Research Council muscle grading, or assessments of daily activities, to complement self-reported outcomes.

Finally, though the participants were recruited from the same day care center, there was significant variability in their pain levels, visual abilities, and experience with VR technology. This heterogeneity could influence the results. It made it challenging to attribute outcomes solely to the VR intervention. Future research should use stratified analyses or larger samples from various locations to control for these variables. This would provide clearer insights into the intervention’s effects.

Beyond the limitations above, several practical questions also require exploration. Research in various community settings is essential to evaluate scalability. These studies should consider the current headset cost (approximately US $500) and examine the facilitator-to-participant ratio used in this study. Here, one trained staff member supported 5-6 seated users after initial training. Cost-effectiveness studies and mixed methods research on implementation would further guide real-world use. By tackling these gaps, future work can build a strong evidence base for using commercial virtual reality applications with older adults living in the community.

This pilot study represents a pioneering exploration into the use of nonlocalized and commercial-off-the-shelf VR applications to manage chronic pain and well-being among older adults in community settings. This pilot demonstrated that despite language barriers, insufficient digital literacy, and cultural differences, these VR applications demonstrated good feasibility and acceptability among older adults through structured programs. Specifically, high completion rates, low adverse outcomes, and positive qualitative feedback attested to their promising prospects for application. In this uncontrolled sample, VR sessions were associated with large, within-group improvements in mood and modest gains in pain self-efficacy. While causal inferences cannot be drawn due to limitations in methodology, this study lays the groundwork for more rigorous future exploration. Through continuous research, development, and validation, VR technology is expected to become an economical, convenient, and effective nonpharmacological intervention for chronic pain management in older adults, thereby promoting aging in place and comprehensively improving their quality of life.